I know Julio Montaner since 1995, the year before the Vancouver Conference, at the beginning of the HAART revolution. Julio Montaner is director of the BC Centre for Excellence in HIV/AIDS and Past President of the International AIDS Society: a forceful person, being able to conjugate the passion of a latin man together with the strictness of the north-American character. If you consider the fact that he lives in Vancouver, that is a sort of pot of different cultures and a living experiment of modernity, you can understand his will to make a passionate difference in the field in which he is involved. In order to give the flavor of his enthusiasm I want to put the literal transcript of the beginning of our conversation that we made in Rome during the IAS Conference, immediately after the publication of the HPTN052 study and his commentary on The Lancet. “Well – you know? – you know (smiling) I’m honored, really, after nearly a decade of working dedicatedly to try to demonstrate the benefit, the secondary benefit that HIV treatment has on preventing not only tuberculosis not only a number of other things, but most importantly preventing HIV transmission…” The end of his commentary on The Lancet is: “The evidence is in: treatment is prevention. Treatment dramatically prevents morbidity and mortality, HIV transmission, and tuberculosis. Furthermore, treatment prevents HIV transmission in vertical, sexual, and injection drug use settings; indeed, a very welcome double hat-trick. The challenge remains to optimise the impact of this valuable intervention. Failure to do so is not an option”.
Treatment is prevention, a revolution that was spread all over the world from the IAS conference in Rome, but it was started in British Columbia.
Yes. We now have definitive proof that when you treat a serodiscordant couple, the treatment of the person infected with HIV is not only good for his or her health, but also decreases transmission by 96%. Those results are absolutely fabulous, and I would say more: that estimate is derived from one case where there was transmission and the transmission occurred probably just before the person had started with antiretroviral therapy or immediately after, indicating that antiretroviral therapy, after it has an opportunity to become active -few weeks, two months- and the person becomes undetectable, is virtually 100% effective at stopping transmission.
Today we have many tools that we can use to stop the epidemic, but the most important tool, the one that gives you the greatest return for your investment, is antiretroviral therapy of those infected with HIV. Why? Because it decreases disease progression, it decreases mortality, it prevents tuberculosis in a dramatic fashion, but even more important it decrease HIV transmission by nearly 100%: nothing comes close to it. So, we need to tell the leaders of the world “If you deliver the 15 million that you promise by 2015 on antiretroviral therapy in the south of the world, the curves are going to bend dramatically. We’re going to see a dramatic change in the course of the epidemic”. We are at a point where we can start talking about the end of AIDS.
The HPTN052 study is the last chapter of a story made possible by a new concept set up by you and your team: ”community viral load”. Could you define this concept and make the history of it?
The community viral load is a measurement that we originally introduced with the work that my colleague Evan Wood did in the Downtown Eastside of Vancouver, which is the neighborhood where the injection drug use epidemic is concentrated in my city. We were trying to look at the issue of the role of treatment roll-out on prevention and we found that it was very difficult to identify the couples of injection drug users that were sharing needles where there was an issue of being serodiscordant about HIV status. So, quite ingeniously, he came up with the notion that instead of looking at this issue at the individual level, we could look at it at the community level. Having had measurements of viral load continuously on these patients over a period of ten years, we were able to show that if you take the viral load in all of those that are HIV positive and you calculate whether is a median or an average, -in this case we used the median- you can describe the community viral load over time. Then, we were able to show that starting the measurement in 1996, the viral load in that community decreased steadily with the introduction of antiretroviral therapy from 6 logs at the beginning to undetectable levels a few years thereafter. And in the paper that we published in the British Medical Journal a couple of years ago now, we showed that the community viral load was the strongest predictor of HIV seroconversion in the subsequent period of observation. So striking was this, that, for example if you consider the relative risk associated to needle sharing for HIV seroconversion, subsequent seroconversion, in that case the risk was elevated by a twofold while the viral load in the treatment cohort at the beginning of the study was associated with a relative risk of 20, which is to say ten-fold greater risk than needle sharing. The message is very simple: if you control the community viral load, you can share needles, you can get hepatitis C or the other infections, but the likelihood of getting HIV when the viremia is suppressed in the community is remote. Since then, a number of other groups have taken the community viral load measurement and applied it to a larger scale; during last CROI it was presented a study about community viral load in San Francisco where they have shown that as community viral load over time goes down in San Francisco, the number of new infections are also going down. This is something that we have shown for the entire other provinces in British Columbia and we published it in the Lancet last summer a paper where we showed a nice correlation between increasing antiretroviral therapy coverage and decrease in HIV new infections.
Do you think that this kind of approach can in some way make a revolution also in public health because – you know? – taking a pill means to take care of ourselves but in this case taking a pill means collective goods?
My father was a TB doctor and he always told me when you treat a person with tuberculosis, that individual, virtually, the moment he starts treatment, from a public health perspective is no longer a problem because in a matter of days, two weeks, two months, that person will stop spitting Mycobacterium tuberculosis and therefore the best thing that you can do for the epidemic is to find the cases, offer them treatment, help them to take the treatment and you can solve the problem. In HIV now we want to bring the treatment to the people in a facilitated fashion, offer them the opportunity to test in a supportive environment, reduce the discrimination, reduce the barriers because helping them to do the best for themselves is the best for public health.
So “test & treat” will be the shift from individual to community?
Treatment first and foremost is associated with individual benefit, but the effect of treatment on the community is what is the real game-changer because what happens is that while the effect of treatment on the individual is cost-effective, by adding to it the preventive value of a treatment in the interest of decreasing the spread of HIV, that transforms the treatment in a cost averting, or potentially cost averting or, more importantly, an exit strategy, as we call it, in terms of being an essential tool to stop the epidemic and eventually to control it once and for all.
So, we are not trying to put the emphasis on the community above the emphasis on the individual: we need to be extremely clear that today, given that we know that HIV is bad for you and that is associated with inflammatory consequences, that hurts your solid organs, that is associated with cardiac death, with liver associated-disease and death eventually and so on and so forth, for all of those reasons even before immunodeficiency supervenes, treatment is the way forward for the individual, but in embracing this our policy makers will be making the best that they possibly can to control the epidemic.
It is a win-win strategy: what is positive for the individual becomes a good outcome for the community
If we do what we know that works for the individual and for the communities under the sort of the slogan of “combination prevention”, “Treatment 2.0” or whatever title you want to give it, we are going to be able to control the spread of HIV, at the same time that we with deal with morbidity and mortality related to AIDS. At the end of the day, it is a triple winner, we can’t afford not to do it.
Articolo presente in – HAART and correlated pathologies n. 12 –